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["特別養護老人ホームアイリス\n特別養護老人ホームアイリス弐番館\n入所申込書（その１）"]
[]
[null,"特別養護老人ホーム"]
[null,"　","アイリス",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※受付№"]
[null,null,"アイリス弐番館",null,null,null,null,null,null,null,"施設長　様",null,null,null,null,null,"申込日",null,null,null,null,null,"　   令和　  　　　　年　　　　　月　　　　　日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※受付日",null,null,null,null,null,"　   令和  　　　　　年　　　　　月　　　　　日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"「※」欄に関しては記載しないこと"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申 込 者",null,"住所",null,null,null,"〒"]
["※入所を希望する施設に☑を入れて下さい。"]
["□","特別養護老人ホームアイリス（従来型）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(ふりがな）",null,null,null,null,null,null,null,null,null,null,null,null,null,"本人との関係"]
["□","特別養護老人ホームアイリス弐番館（ユニット型）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏 名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号"]
[null,"特別養護老人ホームへ入所したいので、次の通り申し込みます。"]
["本　人　の　状　況",null,"（ふりがな）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",null,null,null,"保険者\n（市区町村名）"]
[null,null,"氏 名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男 ・ 女"]
[null,null,"生年月日",null,null,null,"明治　・　大正　・　昭和",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 被保険者番号"]
[null,null,null,null,null,null,"　　　　　年　　　　月　　　　日　　（　　　　　歳）　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護度",null,null,null,null,"１　・　２　・　３　・　４　・　５"]
[null,null,"住  所",null,null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護認定期間",null,null,null,null,"令和　　　年　　　月　　　日から"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和　　　年　　　月　　　日まで"]
[null,null,"現在利用している在宅サービスの状況\n\n（　　　）内は事業所名を記入して下さい。"]
[null,null,null,null,null,null,null,1,"訪問介護",null,null,null,"（",null,null,null,null,null,null,null,null,"）",6,"通所リハビリ\nテーション",null,null,null,"（",null,null,null,null,null,null,null,"　　","）"]
[null,null,null,null,null,null,null,"　","開始日",null,null,"　　　　年　　　月/　　　月　　　回",null,null,null,null,null,null,null,null,null,null,null,"開始日",null,null,"　　　　年　　　月/　　　月　　　回"]
[null,null,null,null,null,null,null,2,"訪問入浴介護",null,null,null,"（　　　　　　　　　　　　　　　　　　　）",null,null,null,null,"　　","　",null,"　　　　　","）",7,"短期入所\n生活介護",null,null,null,"（",null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,"開始日",null,null,"　　　　年　　　月/　　　月　　　回",null,null,null,null,null,null,null,null,null,null,null,"開始日",null,null,"　　　　年　　　月/　　　月　　　回"]
[null,null,null,null,null,null,null,3,"訪問看護",null,null,null,"（　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,"）",8,"短期入所\n療養介護",null,null,null,"（",null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,"開始日",null,null,"　　　　年　　　月/　　　月　　　回",null,null,null,null,null,null,null,null,null,null,null,"開始日",null,null,"　　　　年　　　月/　　　月　　　回"]
[null,null,null,null,null,null,null,4,"訪問リハビリテーション",null,null,null,"（",null,null,null,null,null,null,null,null,"）",9,"福祉用具貸与・購入費の支給"]
[null,null,null,null,null,null,null,null,"開始日",null,null,"　　　　年　　　月/　　　月　　　回"]
[null,null,null,null,null,null,null,5,"通所介護",null,null,null,"（　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,"）",10,"その他"]
[null,null,null,null,null,null,null,null,"開始日",null,null,"　　　　年　　　月/　　　月　　　回"]
[]
[null,null,null,null,null,null,null,null,null,1,"一人暮らし、又は介護者がいないため"]
[null,null,"入居を希望する理由",null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,"（該当する番号に○をつけて下さい）",null,null,null,null,null,null,2,"介護者がいるが障害や疾病の状況にあり介護が困難なため"]
[null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,3,"介護者がいるが高齢等のため十分な介護が困難なため"]
[null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,"※（　　）内は具体的な理由を記入して下さい。",null,null,null,null,null,null,4,"介護者がいるが就業しているため十分な介護が困難なため"]
[null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,5,"介護者がいるが育児又は家族が病気の状況にあり十分な介護が困難なため"]
[null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,6,"介護保険施設に入居しているが替わりたい"]
[null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,7,"その他",null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,"現 在 の 状 況",null,null,null,null,null,null,1,null,"病院",null,"（入院先：",null,null,null,null,null,null,null,null,null,null,"期間 ：令和　　年　　月　　日 ～",null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,2,null,"施設",null,"（施設名：",null,null,null,null,null,null,null,null,null,null,"期間 ：令和　　年　　月　　日 ～",null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,3,null,"在宅",null,null,null,null,null,null,null,4,"その他（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]

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["特別養護老人ホームアイリス・アイリス弐番館　入所申込書（その２）"]
[null,"介　護　者　の　状　況","単身生活者の場合",null,null,null,null,"１　介護者がいる",null,null,null,null,null,null,null,"２　介護者がいない"]
[null,null,"主たる介護者",null,null,null,null,"　（ふりがな）",null,null,null,null,null,null,null,null,null,null,"男 ・ 女",null,"本人との関係"]
[null,null,null,null,null,null,null,"氏　　　名"]
[null,null,null,null,null,null,null,"生年月日",null,null,"明治・大正・昭和",null,null,null,null,"　　　　　　年　　　　　月　　　　　日",null,null,null,null,null,null,"　（　　　　歳）"]
[null,null,null,null,null,null,null,"同居の区分",null,null,1,null,"同居"]
[null,null,null,null,null,null,null,null,null,null,2,null,"別居（住所：",null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"複数介護　　　　の有無",null,null,1,null,"あり","（①介護困難",null,null,null,"②多少介護可能",null,null,null,"　③介護可能",null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,2,null,"なし"]
[null,null,null,null,null,null,null,"就労状況",null,null,null,null,null,"育児・家庭の状況",null,null,null,null,null,null,"健康状態"]
[null,null,null,null,null,null,null,"　１ 　あり",null,null,null,null,null,"　１ 　あり",null,null,null,null,null,null,"　１ 　良好"]
[null,null,null,null,null,null,null,"　①","８時間以上",null,null,null,null,"　①常時の育児・看護が必要",null,null,null,null,null,null,"　２ 疾病又は障害あり"]
[null,null,null,null,null,null,null,null,"高齢で就労不能",null,null,null,null,"　②半日の育児・看護が必要",null,null,null,null,null,null,"　①　介護困難"]
[null,null,null,null,null,null,null,"　②","４時間以上８時間未満",null,null,null,null,"　③時々の育児・看護が必要",null,null,null,null,null,null,"　②　多少介護可能"]
[null,null,null,null,null,null,null,"　③","４時間未満",null,null,null,null,"　④６５歳以上の高齢者のみ",null,null,null,null,null,null,"　③　介護可能"]
[null,null,null,null,null,null,null,"　２　なし",null,null,null,null,null,"　２　なし"]
[null,null,"従たる介護者",null,null,null,null,"（ふりがな）",null,null,null,null,null,null,null,null,null,"男 ・ 女",null,"本人との関係"]
[null,null,null,null,null,null,null,"氏　　名"]
[null,null,null,null,null,null,null,"同居の区分",null,null,null,"1　同居"]
[null,null,null,null,null,null,null,null,null,null,null,"２　別居",null,"（住所：　",null,null,null,null,null,null,null,null,null,"　　）"]
[null,null,null,null,null,null,null,"同居介護　　　者の状況",null,null,null,"1　従たる同居介護者なし"]
[null,null,null,null,null,null,null,null,null,null,null,"２　従たる同居介護者あり"]
[null,null,null,null,null,null,null,null,null,null,null,null,"①介護困難",null,null,null,"②多少介護可能",null,null,null,"     ③介護可能"]
[null,null,"別居血縁者による　　　介護の可能性",null,null,null,null,"　１　別居している血縁者なし"]
[null,null,null,null,null,null,null,"　２　別居している血縁者あり"]
[null,null,null,null,null,null,null,null,"①介護困難",null,null,null,null,"②多少介護可能",null,null,null,null,"③介護可能"]
[null,null,"介護期間",null,null,null,null,"　　　　　　　　年　　　　　ヶ月"]
[null,"その他","入居を希望する時期",null,null,null,null,"　令和　　　　年　　　　月頃までに入居したい",null,null,null,null,null,null,null,null,"理由（　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,"他施設への　　　　　　　　申込み状況",null,null,null,null,"　施設名：",null,null,null,null,null,null,null,null,"施設名："]
[null,null,null,null,null,null,null,"　申込日：",null,"令和　　　　年　　　　月　　　　日",null,null,null,null,null,null,"申込日：",null,"令和　　　　　年　　　　月　　　　日"]
[null,null,null,null,null,null,null,"　施設名：",null,null,null,null,null,null,null,null,"施設名："]
[null,null,null,null,null,null,null,"　申込日：",null,"令和　　　　年　　　　月　　　　日",null,null,null,null,null,null,"申込日：",null,"令和　　　　　年　　　　月　　　　日"]
[null,null,"居宅において日常生活を行うことが困難であることについてのやむを得ない事由（要介護１又は２のみ記載）",null,null,null,null,"□","認知症である者であって、日常生活に支障を来すような症状・行動や意思疎通の"]
[null,null,null,null,null,null,null,null,"困難さが頻繁に見られる"]
[null,null,null,null,null,null,null,"□","知的障害・精神障害等を伴い、日常生活に支障を来すような症状・行動や意思疎"]
[null,null,null,null,null,null,null,null,"疎通の困難さ等が頻繁に見られる"]
[null,null,null,null,null,null,null,"□","家族等による深刻な虐待等が疑われること等により、心身の安全・安心の確保が"]
[null,null,null,null,null,null,null,null,"困難である"]
[null,null,null,null,null,null,null,"□","単身世帯である、同居家族が高齢又は病弱である等により家族等による支援が期"]
[null,null,null,null,null,null,null,null,"待できず、かつ、地域での介護サービスや生活支援の供給が不十分な状況である"]
[null,"説明確認","　　私は入居申込の際、入居決定の手続き及び入居の必要性を評価する基準等について"]
[null,null,"　施設から説明を受けました。"]
[]
[null,null,"　令和　　　　　年　　　　　月　　　　　日　　　　　",null,null,null,null,null,null,null,null,null,null,null,"氏名　　　　　　　　　　　　　　　　　　　　　　　　　印　"]
[null,"添付書類（以下の書類を申込書と一緒にご提出ください）"]
[null,"1　認定調査の写し",null,null,null,null,"２　主治医意見書の写し",null,null,null,null,null,null,"３　最近３ヶ月のサービス利用票の写し"]
[null,"４　介護保険被保険者証の写し",null,null,null,null,null,null,null,"５　介護保険負担割合証の写し"]
[null,"６　介護保険負担限度額認定証の写し"]
[null,"※１","入居の必要がなくなった場合は、別紙「特別養護老人ホーム入所申込取り下げ書」を提出してください。"]
[null,"※２","申込内容に変更が生じた場合は、施設にご連絡ください。"]

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["入所申込現況調査票（１）"]
[]
[null,null,null,null,null,null,null,null,null,null,"記入日",null,"令和　　　　年　　　　　月　　　　　日"]
[]
["ふりがな",null,null,null,null,null,null,null,null,null,"男・女","要介護度"]
["氏　　名",null,null,null,null,null,null,null,null,null,null,"認定の有効期間"]
[null,null,null,null,null,null,null,null,null,null,null,null,"令和　　　　年　　　　月　　　　　日"]
[null,null,null,null,null,null,null,null,null,null,null,null,"令和　　　　年　　　　月　　　　　日"]
["住　　　所",null,null,null,"〒"]
["本　　　籍"]
["生  年  月  日",null,null,null,"　明治 ・ 大正 ・ 昭和",null,null,null,"　　　年　　　　　　　　　月　　　　　　　　日（　　　　　　　歳）"]
["家 族 の 状 況","　連絡先",null,null,"　氏名",null,null,null,null,null,"住所"]
[null,"①身元保証人"]
[null,null,null,null,"　　　　　　年　　　月　　　　日生　　電話　　　　　　　　　　　携帯"]
[null,"②身元保証人",null,null,"　氏名",null,null,null,null,null,"住所"]
[]
[null,null,null,null,"　　　　　　年　　　月　　　　日生　　電話　　　　　　　　　　　携帯"]
[null,"　家族構成",null,null,null,null,null,null,null,null,"　入居希望の理由（現状経過）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["本　人　の　状　況","既往歴"]
[null,"現　病"]
[null,"かかりつけ医",null,null,"医院名",null,null,null,null,"主治医",null,null,null,null,"TEL"]
[null,null,null,null,"医院名",null,null,null,null,"主治医",null,null,null,null,"TEL"]
[null,"服　　　薬",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※別にお薬説明書を添付して頂いても結構です。"]
[null,"医療的処置\n（該当するものを選んでください）",null,null,"有　・　無"]
[null,null,null,null,"１．　尿カテーテル　　２．　ストマ（人工肛門）　　３．　胃瘻　　４．　経鼻経管栄養　\n５．　酸素療法　　６．　インシュリン注射（自己注射・他者注射）　　７．　褥瘡処置　　\n８．　吸引　　９．　疼痛管理　　１０．　点眼　　１１．その他（　　　　　　　　　　　　　　　）"]
[null,"生活歴等"]
[null,"収　　　入",null,null,"年金種類",null,"国民  ・  厚生  ・  共済  ・  遺族  ・  その他",null,null,null,null,null,null,null,"　その他の収入"]
[null,"（年金・恩給）",null,null,"年　額",null,null,null,"年","/",null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"特別養護老人ホームアイリス・アイリス弐番館"]

{"sheet":"調査票２","index":3,"n_rows":41,"n_cols":26,"rows_kept":41,"cut":false,"hidden":false,"merged":[[0,0,0,25],[1,0,6,1],[6,2,6,25],[7,0,20,1],[21,0,28,1],[8,19,8,25],[9,19,9,25],[8,16,8,18],[9,16,9,18],[17,2,17,5],[21,15,21,25],[1,6,1,9],[1,2,1,5],[29,0,34,1],[34,2,34,25],[35,0,37,1],[38,0,39,1],[38,2,38,10],[38,19,38,25],[35,2,35,7],[37,10,37,11],[35,18,37,25],[38,11,38,18],[39,2,39,13],[39,14,39,25],[35,9,35,12],[29,6,29,16],[29,17,29,19],[30,5,30,25],[31,5,31,25],[11,16,11,25],[12,16,12,25],[25,5,25,12],[27,17,27,25],[23,16,23,25]]}
["入所申込現況調査票（２）"]
["認知症等",null,"　認知症",null,null,null,"　有　・　無　",null,null,null,"（　年齢相応　・　軽度　・中度　・　重度　・　不明　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※複数選択可"]
[null,null,"　暴言・暴力",null,null,null,"（　有 ・ 無　）",null,null,null,"　徘徊",null,null,null,"（　有 ・ 無　）",null,null,null,"　収集癖",null,null,null,"（　有 ・ 無　）"]
[null,null,"　昼夜逆転",null,null,null,"（　有 ・ 無　）",null,null,null,"　幻視・幻覚",null,null,null,"（　有 ・ 無　）",null,null,null,"　不定愁訴",null,null,null,"（　有 ・ 無　）"]
[null,null,"　不潔行為",null,null,null,"（　有 ・ 無　）",null,null,null,"　介護拒否",null,null,null,"（　有 ・ 無　）",null,null,null,"　異食",null,null,null,"（　有 ・ 無　）"]
[null,null,"　帰宅願望",null,null,null,"（　有 ・ 無　）",null,null,null,"　大声を出す",null,null,null,"（　有 ・ 無　）",null,null,null,"　妄想・作話",null,null,null,"（　有 ・ 無　）"]
[null,null,"上記内容で「有」と答えた箇所に関して、詳細な状況を記載して下さい"]
["身 体 機 能",null,"　身長　　　　　　　　　㎝　　　　　　　　体重　　　　　　　　㎏"]
[null,null,"　起き上がり",null,null,null,"（ 自立 ・ 見守り ・ 一部介助 ・ 全介助 ）",null,null,null,null,null,null,null,null,null,"座位保持",null,null,"（ 可 ・ 支えて可 ・ 不可）"]
[null,null,"　寝返り",null,null,null,"（ 自立 ・ 見守り ・ 一部介助 ・ 全介助 ）",null,null,null,null,null,null,null,null,null,"立位保持",null,null,"（ 可 ・ 支えて可 ・ 不可）"]
[null,null,"　移動手段",null,null,null,"（ 歩行　・　杖歩行　・　シルバーカー　・　サークル歩行器　・　車椅子 )"]
[null,null,"　移動動作",null,null,null,"（ 自立 ・ 見守り ・ 一部介助 ・ 全介助 ）",null,null,null,null,null,null,null,null,null,"※車椅子の場合　　（　自操可　・　不可　）"]
[null,null,"　移乗動作",null,null,null,"（ 自立 ・ 見守り ・ 一部介助 ・ 全介助 ）",null,null,null,null,null,null,null,null,null,"　　　　　※ふらつき　（　有　・　無　）"]
[null,null,"　麻痺",null,null,null,"（　有 ・ 無　）",null,null,null,"部位",null,"(　右上肢　･　右下肢　･　左上肢　･　左下肢　･　その他　)"]
[null,null,"　拘縮",null,null,null,"（　有 ・ 無　）",null,null,null,"部位",null,"(　右上肢　･　右下肢　･　左上肢　･　左下肢　･　その他　)"]
[null,null,"　衣類の着脱",null,null,null,"(　自立　･　見守り　･　一部介助　・　全介助　）"]
[null,null,"　言葉",null,null,null,"（　話せる ・聞き取りにくい ・ 単語のみ ・ 不可 ・ 言語障害　）"]
[null,null,"　コミュニケーション",null,null,null,"（　可　・　時々通じる　・　簡単な言葉ならば可　・　ほとんど不可　・　不可　）"]
[null,null,"　視力",null,null,null,"（　普通 ・ あまり見えない ・ 見えない ・ 判断できず　）"]
[null,null,"　聴力",null,null,null,"（　普通　・　大声　・　補聴器　・　聞こえない　・　判断できず）"]
[null,null,"　その他　"]
["食　　　事",null,"　食事",null,null,"自立　･　見守り　･　一部介助　・　全介助　",null,null,null,null,null,null,null,null,null," （ はし ・ スプーン ・ フォーク ・ 自助具 ・ エプロン ）"]
[null,null,"　嚥下",null,null,"普通　・　時々むせる　・　とろみをつける　・　困難　",null,null,null,null,null,null,null,null,null,null,null,null,"水分とろみ　　（　有　・　無　）"]
[null,null,"　形態",null,null,"主食",null,"（　常食　・　軟飯　・　粥　・　ミキサー　）",null,null,null,null,null,null,null,null,"パン　（ 可 ・不可 ）　　麺　（ 可・不可 ）"]
[null,null,null,null,null,"副食",null,"（　常食　・　一口大　・　刻み　・　極刻み　・　ミキサー　）"]
[null,null,"　義歯",null,null,"（　上 ・ 下 ・ 部分 ・ 無　）",null,null,null,null,null,null,null,"　好きなもの",null,null,null,null,null,"　嫌いなもの"]
[null,null,"　禁食",null,null,"無　・　嗜好　・　服薬　・　その他　　　品目（　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,"　療養食",null,null,"無　・　塩分　・　カロリー　・　その他（　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,"対応内容　（　　　　　　　　　　　　　　　）"]
[null,null,"　その他"]
["清　 潔",null,"　排泄",null,null,null,"　自立　･　見守り　･　一部介助　・　全介助　"]
[null,null,"　日中",null,null,"　トイレ ・ Ｐトイレ ・ 尿器　・ その他　　（　オムツ ・ リハビリパンツ ・ パット ・ 布パンツ　)"]
[null,null,"　夜間",null,null,"　トイレ ・ Ｐトイレ ・ 尿器　・ その他　　（　オムツ ・ リハビリパンツ ・ パット ・ 布パンツ　)"]
[null,null,"　入浴",null,null,null,"　自立　･　見守り　･　一部介助　・　全介助　"]
[null,null,"　入浴の種類",null,null,null,"（　特殊浴　・　中間浴　・　一般浴　・　シャワー浴）"]
[null,null,"　その他"]
["睡 眠",null,"　ベッド　・　床",null,null,null,null,null,null,"センサー使用",null,null,null,"（　有 ・ 無　）",null,null,null,null,"夜間帯の様子"]
[null,null,"　睡眠",null,null,null,"（　良眠　・　浅眠　・　時折不眠　・　不眠　）"]
[null,null,"　眠剤使用",null,null,null,"（　有　・　無　）",null,null,null,"薬名",null,"(　",null,null,null,null,"）"]
["性格等",null,"　性格",null,null,null,null,null,null,null,null,"　趣味",null,null,null,null,null,null,null,"　嗜好（酒・タバコ）"]
[null,null,"　本人の希望",null,null,null,null,null,null,null,null,null,null,null,"　家族の希望"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"特別養護老人ホームアイリス・アイリス弐番館"]

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["特別養護老人ホームアイリス\n特別養護老人ホームアイリス弐番館\n入所申込書（その１）"]
[]
[null,"特別養護老人ホーム"]
[null,"　","アイリス",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※受付№"]
[null,null,"アイリス弐番館",null,null,null,null,null,null,null,"施設長　様",null,null,null,null,null,"申込日",null,null,null,null,null,"令和　 　３ 　　年 　 １０　　月　　１　　日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※受付日",null,null,null,null,null," 令和  　　　　　年　　　　　　月　　　　　日"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申 込 者",null,"住所",null,null,null,"〒","350-0831"]
["※入所を希望する施設に☑を入れて下さい。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"川越市府川２４３-２"]
["☑","特別養護老人ホームアイリス（従来型）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(ふりがな）",null,null,null,"あいりす　たろう",null,null,null,null,null,null,null,null,null,"本人との関係"]
["□","特別養護老人ホームアイリス弐番館（ユニット型）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏 名",null,null,null,"アイリス　太郎",null,null,null,null,null,null,null,null,null,"長男"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,"０４９-２７７-５０８８"]
[null,"特別養護老人ホーム「真和の森」へ入居したいので、次の通り申し込みます。"]
["本　人　の　状　況",null,"（ふりがな）",null,null,null,null,null,"あいりす　いちろう",null,null,null,null,null,null,null,null,null,"性別",null,null,null,"保険者\n（市町村名）",null,null,null,null,"川越市"]
[null,null,"氏 名",null,null,null,null,null,"アイリス　一郎",null,null,null,null,null,null,null,null,null,"男 ・ 女",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"1965-04-01"]
[null,null,"生年月日",null,null,null,"明治　・　大正　・　昭和",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 被保険者番号",null,null,null,null,0,1,2,3,4,5,6,7,8,9]
[null,null,null,null,null,null,"○○　年　　○　月　　○　日　　（　○○　歳）　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護度",null,null,null,null,"１　・　２　・　３　・　４　・　５",null,null,null,null,null,null,null,null,null,null,null,{"$f":"DATEDIF(AN15,TODAY(),\"y\")","v":59}]
[null,null,"住  所",null,null,null,"〒","３５０-０８２２",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護認定期間",null,null,null,null,"令和　３　年　４　月　１　日から"]
[null,null,null,null,null,null,"川越市山田１５２６-１",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和　４ 　年　３ 　月　３１　日まで"]
[null,null,"現在利用している在宅サービスの状況\n\n（　　　）内は事業所名を記入して下さい。"]
[null,null,null,null,null,null,null,1,"訪問介護",null,null,null,"（",null,null,null,null,null,null,null,null,"）",6,"通所リハビリ\nテーション",null,null,null,"（",null,null,null,null,null,null,null,"　　","）"]
[null,null,null,null,null,null,null,"　","開始日",null,null,"　　年　　　月/　　　月　　　回",null,null,null,null,null,null,null,null,null,null,null,"開始日",null,null,"　　年　　　月/　　　月　　　回"]
[null,null,null,null,null,null,null,2,"訪問入浴介護",null,null,null,"（　　　　　　　　　　　　　　　　　　　）",null,null,null,null,"　　","　",null,"　　　　　","）",7,"短期入所\n生活介護",null,null,null,"（","４～６日/月",null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,"開始日",null,null,"　　年　　　月/　　　月　　　回",null,null,null,null,null,null,null,null,null,null,null,"開始日",null,null,"　　年　　　月/　　　月　　　回"]
[null,null,null,null,null,null,null,3,"訪問看護",null,null,null,"（　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,"）",8,"短期入所\n療養介護",null,null,null,"（",null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,"開始日",null,null,"　　年　　　月/　　　月　　　回",null,null,null,null,null,null,null,null,null,null,null,"開始日",null,null,"　　年　　　月/　　　月　　　回"]
[null,null,null,null,null,null,null,4,"訪問リハビリテーション",null,null,null,"（",null,null,null,null,null,null,null,null,"）",9,"福祉用具貸与・購入費の支給"]
[null,null,null,null,null,null,null,null,"開始日",null,null,"　　年　　　月/　　　月　　　回",null,null,null,null,null,null,null,null,null,null,null,"車椅子のレンタル　スロープレンタル"]
[null,null,null,null,null,null,null,5,"通所介護",null,null,null,"（　週に２回利用している",null,null,null,null,null,null,null,null,"）",10,"その他"]
[null,null,null,null,null,null,null,null,"開始日",null,null,"令和 １ 年 １２ 月/　月　８　回"]
[]
[null,null,null,null,null,null,null,null,null,1,"一人暮らし、又は介護者がいないため"]
[null,null,"入居を希望する理由",null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,"（該当する番号に○をつけて下さい）",null,null,null,null,null,null,2,"介護者がいるが障害や疾病の状況にあり介護が困難なため"]
[null,null,null,null,null,null,null,null,null,null,"（","慢性疾患により月に数回病院受診が必要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,3,"介護者がいるが高齢等のため十分な介護が困難なため"]
[null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,"※（　　）内は具体的な理由を記入して下さい。",null,null,null,null,null,null,4,"介護者がいるが就業しているため十分な介護が困難なため"]
[null,null,null,null,null,null,null,null,null,null,"（","正社員で働いており、日中の介護は困難",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,5,"介護者がいるが育児又は家族が病気の状況にあり十分な介護が困難なため"]
[null,null,null,null,null,null,null,null,null,null,"（","小学生の子供がおり、介護が困難",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,6,"介護保険施設に入居しているが替わりたい"]
[null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,7,"その他",null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,"現 在 の 状 況",null,null,null,null,null,null,1,null,"病院",null,"（入院先：",null,null,null,null,null,null,null,null,null,null,null,"期間 ：令和　　年　　月　　日 ～",null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,2,null,"施設",null,"（施設名：",null,null,null,null,null,null,null,null,null,null,null,"期間 ：令和　　年　　月　　日 ～",null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,3,null,"在宅",null,null,null,null,null,null,null,4,"その他（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]

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["特別養護老人ホーム　アイリス・アイリス弐番館　入所申込書（その２）"]
[null,"介　護　者　の　状　況","単身生活者の場合",null,null,null,null,"１　介護者がいる",null,null,null,null,null,null,"２　介護者がいない"]
[null,null,"　　　　　　　　　　　　　主たる介護者　　　　　※主に介護を\nしている方\n　　　",null,null,null,null,"　（ふりがな）",null,null,"アイリス　たろう",null,null,null,null,null,null,null,"男 ・ 女",null,"本人との関係"]
[null,null,null,null,null,null,null,"氏　　　名",null,null,"アイリス　太郎",null,null,null,null,null,null,null,null,null,"長男"]
[null,null,null,null,null,null,null,"生年月日",null,null,"明治・大正・昭和",null,null,null,null,"　　４０　年　　４　月　　１　日",null,null,null,null,null,null,"　（　５３　歳）"]
[null,null,null,null,null,null,null,"同居の区分",null,null,1,null,"同居"]
[null,null,null,null,null,null,null,null,null,null,2,null,"別居（住所：",null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"複数介護　　　　の有無",null,null,1,null,"あり","（①介護困難",null,null,null,"②多少介護可能",null,null,null,"　③介護可能",null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,2,null,"なし"]
[null,null,null,null,null,null,null,"就労状況",null,null,null,null,null,"育児・家庭の状況",null,null,null,null,null,null,"健康状態"]
[null,null,null,null,null,null,null,"　１ 　あり",null,null,null,null,null,"　１ 　あり",null,null,null,null,null,null,"　１ 　良好"]
[null,null,null,null,null,null,null,"　①","８時間以上",null,null,null,null,"　①常時の育児・看護が必要",null,null,null,null,null,null,"　２ 疾病又は障害あり"]
[null,null,null,null,null,null,null,null,"高齢で就労不能",null,null,null,null,"　②半日の育児・看護が必要",null,null,null,null,null,null,"　①　介護困難"]
[null,null,null,null,null,null,null,"　②","４時間以上８時間未満",null,null,null,null,"　③時々の育児・看護が必要",null,null,null,null,null,null,"　②　多少介護可能"]
[null,null,null,null,null,null,null,"　③","４時間未満",null,null,null,null,"　④６５歳以上の高齢者のみ",null,null,null,null,null,null,"　③　介護可能"]
[null,null,null,null,null,null,null,"　２　なし",null,null,null,null,null,"　２　なし"]
[null,null,"従たる介護者\n※上記の方に続い\nて介護をしている方\n",null,null,null,null,"（ふりがな）",null,null,"あいりす　はなこ",null,null,null,null,null,null,"男 ・ 女",null,"本人との関係"]
[null,null,null,null,null,null,null,"氏　　名",null,null,"アイリス　花子",null,null,null,null,null,null,null,null,"長女"]
[null,null,null,null,null,null,null,"同居の区分",null,null,null,"1　同居"]
[null,null,null,null,null,null,null,null,null,null,null,"２　別居",null,"（住所：　",null,"東京都○○区",null,null,null,null,null,null,null,"　　）"]
[null,null,null,null,null,null,null,"同居介護　　　者の状況",null,null,null,"1　従たる同居介護者なし"]
[null,null,null,null,null,null,null,null,null,null,null,"２　従たる同居介護者あり"]
[null,null,null,null,null,null,null,null,null,null,null,null,"①介護困難",null,null,null,"②多少介護可能",null,null,null,"③介護可能"]
[null,null,"別居血縁者による　　　介護の可能性",null,null,null,null,"　１　別居している血縁者なし"]
[null,null,null,null,null,null,null,"　２　別居している血縁者あり"]
[null,null,null,null,null,null,null,null,"①介護困難",null,null,null,null,"②多少介護可能",null,null,null,null,"③介護可能"]
[null,null,"介護期間",null,null,null,null,"　　　　　５　　　年　　　　　ヶ月"]
[null,"その他","入居を希望する時期",null,null,null,null,"　令和　　　年　　　月頃までに入居したい",null,null,null,null,null,null,null,null,"理由（　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,"他施設への　　　　　　　　申込み状況",null,null,null,null,"　施設名：",null,null,"Ａ特別養護老人ホーム",null,null,null,null,null,"施設名："]
[null,null,null,null,null,null,null,"　申込日：",null,"令和　３　年　２　月　１　日",null,null,null,null,null,null,"申込日：",null,"令和　　　　　年　　　　月　　　　日"]
[null,null,null,null,null,null,null,"　施設名：",null,null,null,null,null,null,null,null,"施設名："]
[null,null,null,null,null,null,null,"　申込日：",null,"令和　　　年　　　　月　　　　日",null,null,null,null,null,null,"申込日：",null,"令和　　　　　年　　　　月　　　　日"]
[null,null,"居宅において日常生活を行うことが困難であることについてのやむを得ない事由（要介護１又は２のみ記載）",null,null,null,null,"□","認知症である者であって、日常生活に支障を来すような症状・行動や意思疎通の"]
[null,null,null,null,null,null,null,null,"困難さが頻繁に見られる"]
[null,null,null,null,null,null,null,"□","知的障害・精神障害等を伴い、日常生活に支障を来すような症状・行動や意思疎"]
[null,null,null,null,null,null,null,null,"疎通の困難さ等が頻繁に見られる"]
[null,null,null,null,null,null,null,"□","家族等による深刻な虐待等が疑われること等により、心身の安全・安心の確保が"]
[null,null,null,null,null,null,null,null,"困難である"]
[null,null,null,null,null,null,null,"□","単身世帯である、同居家族が高齢又は病弱である等により家族等による支援が期"]
[null,null,null,null,null,null,null,null,"待できず、かつ、地域での介護サービスや生活支援の供給が不十分な状況である"]
[null,"説明確認","　　私は入居申込の際、入居決定の手続き及び入居の必要性を評価する基準等について"]
[null,null,"　施設から説明を受けました。"]
[]
[null,null,"　令和　　　　　年　　　　　月　　　　　日　　　　　",null,null,null,null,null,null,null,null,null,null,null,"氏名　　　　　　　　　　　　　　　　　　　　　　　　　印　"]
[null,"添付書類（以下の書類を申込書と一緒にご提出ください）"]
[null,"1　認定調査の写し",null,null,null,null,"２　主治医意見書の写し",null,null,null,null,null,null,"３　最近３ヶ月のサービス利用票の写し"]
[null,"４　介護保険被保険者証の写し",null,null,null,null,null,null,null,"５　介護保険負担割合証の写し"]
[null,"６　介護保険負担限度額認定証の写し"]
[null,"※１","入居の必要がなくなった場合は、別紙「特別養護老人ホーム入所申込取り下げ書」を提出してください。"]
[null,"※２","申込内容に変更が生じた場合は、施設にご連絡ください。"]

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["入所申込現況調査票（１）"]
[]
[null,null,null,null,null,null,null,null,null,null,"記入日",null,"令和　３　年　１０　月　　１　日"]
[]
["ふりがな",null,null,null,"アイリス　いちろう",null,null,null,null,null,"男・女","要介護度",null,null,4]
["氏　　名",null,null,null,"アイリス　一郎",null,null,null,null,null,null,"認定の有効期間"]
[null,null,null,null,null,null,null,null,null,null,null,null,"令和　３　年　４　月　１　日"]
[null,null,null,null,null,null,null,null,null,null,null,null,"令和　４　年　３　月　３１ 日"]
["住　　　所",null,null,null,"〒３５０-０８３１",null,null,null,"川越市府川２４３-２"]
["本　　　籍",null,null,null,null,null,null,null,"埼玉県川越市府川２４３-２"]
["生  年  月  日",null,null,null,"　明治 ・ 大正 ・ 昭和",null,null,null,"　○○　年　　○　　月　　○○　　日（　○○　歳）"]
["家 族 の 状 況","　連絡先",null,null,"　氏名　アイリス　太郎",null,null,null,null,null,"住所　川越市山田１５２６-１"]
[null,"①身元保証人"]
[null,null,null,null,"昭和　４０　年　４　月　１　日生　　電話　○○○○　　携帯　△△△△"]
[null,"②身元保証人",null,null,"　氏名　アイリス　花子",null,null,null,null,null,"住所　東京都〇〇〇区○○○○町○○"]
[]
[null,null,null,null,"昭和　４１　年　２　月　２　日生　　電話　××××　　携帯　□□□□"]
[null,"　家族構成",null,null,null,null,null,null,null,null,"　入居希望の理由（現状経過）"]
[null,null,null,null,null,null,null,null,"Ｈ30年死亡"]
[null,null,null,null,null,null,null,null,null,null,"平成30年本人の妻が死亡した後、独居になる。長男世帯は近隣に住んでいるが、長男夫婦ともにフルタイムの仕事にて常時の介護は難しい。また孫は小学生ということもあり同様に介護困難。長女は東京都にいるが仕事もあるため、介護に携われるのは月に１回程度。\n最近では本人の認知症も進んできており、常時目が離せない状況になってきている。家族の介護負担も限界にきており入所を希望した。"]
[null,"所沢市"]
[null,"　下富"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,"東京都○○○区"]
[]
[null,null,null,null,"川越市"]
[]
["本　人　の　状　況","既往歴",null,null,null,"左大腿骨頚部骨折人工骨頭置換術（Ｈ３１年４月２４日）"]
[null,"現　病",null,null,null,"アルツハイマー型認知症　　高血圧症　糖尿病"]
[null,"かかりつけ医",null,null,"医院名　　Ｃ内科クリニック",null,null,null,null,"主治医　　C 先生",null,null,null,"TEL","〇〇-〇〇〇〇-〇〇〇〇"]
[null,null,null,null,"医院名",null,null,null,null,"主治医",null,null,null,"TEL"]
[null,"服　　　薬",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※別にお薬説明書を添付して頂いても結構です。"]
[null,"医療的処置\n（該当するものを選んでください）",null,null,"有　・　無"]
[null,null,null,null,"１．　バルーンカテーテル　　２．　ストマ（人工肛門）　　３．　胃瘻　　４．　経鼻経管栄養　\n５．　酸素療法　　６．　インシュリン注射（自己注射・他者注射）　　７．　褥瘡処置　　\n８．　吸引　　９．　疼痛管理　　１０．　点眼　　１１．その他（　　　　　　　　　　　　　　　）"]
[null,"生活歴等",null,null,"福岡県に生まれ25歳の時に結婚し二人の子供をもうける。その後転勤にて現在の埼玉県に引っ越し生活をしていた。趣味は野球観戦。平成３０年に妻が死亡した後は徐々に認知症が現れ始め、転倒による骨折にて入院を経て在宅に戻り、現在の状態に至る。"]
[null,"収　　　入",null,null,"年金種類",null,"国民  ・  厚生  ・  共済  ・  遺族  ・  その他",null,null,null,null,null,null,null,"　その他の収入"]
[null,"（年金・恩給）",null,null,"年　額",null,"平成","○○","年","/","１５０万",null,"円",null,"家賃収入\n２００万円/年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"特別養護老人ホームアイリス・アイリス弐番館"]

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["入所申込現況調査票（２）"]
["認知症等",null,"　認知症",null,null,null,"　有　・　無　",null,null,null,"（　年齢相応　・　軽度　・中度　・　重度　・　不明　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※複数選択可"]
[null,null,"　暴言・暴力",null,null,null,"（　有 ・ 無　）",null,null,null,"　徘徊",null,null,null,"（　有 ・ 無　）",null,null,null,"　収集癖",null,null,null,"（　有 ・ 無　）"]
[null,null,"　昼夜逆転",null,null,null,"（　有 ・ 無　）",null,null,null,"　幻視・幻覚",null,null,null,"（　有 ・ 無　）",null,null,null,"　不定愁訴",null,null,null,"（　有 ・ 無　）"]
[null,null,"　不潔行為",null,null,null,"（　有 ・ 無　）",null,null,null,"　介護拒否",null,null,null,"（　有 ・ 無　）",null,null,null,"　異食",null,null,null,"（　有 ・ 無　）"]
[null,null,"　帰宅願望",null,null,null,"（　有 ・ 無　）",null,null,null,"　大声を出す",null,null,null,"（　有 ・ 無　）",null,null,null,"　妄想・作話",null,null,null,"（　有 ・ 無　）"]
[null,null,"上記内容で「有」と答えた箇所に関して、詳細な状況を記載して下さい"]
["身 体 機 能",null,"　身長　　　　　　　　　㎝　　　　　　　　体重　　　　　　　　㎏"]
[null,null,"　起き上がり",null,null,null,"（ 自立 ・ 見守り ・ 一部介助 ・ 全介助 ）",null,null,null,null,null,null,null,null,null,"座位保持",null,null,"（ 可 ・ 支えて可 ・ 不可）"]
[null,null,"　寝返り",null,null,null,"（ 自立 ・ 見守り ・ 一部介助 ・ 全介助 ）",null,null,null,null,null,null,null,null,null,"立位保持",null,null,"（ 可 ・ 支えて可 ・ 不可）"]
[null,null,"　移動手段",null,null,null,"（ 歩行　・　杖歩行　・　シルバーカー　・　サークル歩行器　・　車椅子 )"]
[null,null,"　移動動作",null,null,null,"（ 自立 ・ 見守り ・ 一部介助 ・ 全介助 ）",null,null,null,null,null,null,null,null,null,"※車椅子の場合　　（　自操可　・　不可　）"]
[null,null,"　移乗動作",null,null,null,"（ 自立 ・ 見守り ・ 一部介助 ・ 全介助 ）",null,null,null,null,null,null,null,null,null,"　　　　　※ふらつき　（　有　・　無　）"]
[null,null,"　麻痺",null,null,null,"（　有 ・ 無　）",null,null,null,"部位",null,"(　右上肢　･　右下肢　･　左上肢　･　左下肢　･　その他　)"]
[null,null,"　拘縮",null,null,null,"（　有 ・ 無　）",null,null,null,"部位",null,"(　右上肢　･　右下肢　･　左上肢　･　左下肢　･　その他　)"]
[null,null,"　衣類の着脱",null,null,null,"(　自立　･　見守り　･　一部介助　・　全介助　）"]
[null,null,"　言葉",null,null,null,"（　話せる ・聞き取りにくい ・ 単語のみ ・ 不可 ・ 言語障害　）"]
[null,null,"　コミュニケーション",null,null,null,"（　可　・　時々通じる　・　簡単な言葉ならば可　・　ほとんど不可　・　不可　）"]
[null,null,"　視力",null,null,null,"（　普通 ・ あまり見えない ・ 見えない ・ 判断できず　）"]
[null,null,"　聴力",null,null,null,"（　普通　・　大声　・　補聴器　・　聞こえない　・　判断できず）"]
[null,null,"　その他　"]
["食　　　事",null,"　食事",null,null,"自立　･　見守り　･　一部介助　・　全介助　",null,null,null,null,null,null,null,null,null," （ はし ・ スプーン ・ フォーク ・ 自助具 ・ エプロン ）"]
[null,null,"　嚥下",null,null,"普通　・　時々むせる　・　とろみをつける　・　困難　",null,null,null,null,null,null,null,null,null,null,null,null,"水分とろみ　　（　有　・　無　）"]
[null,null,"　形態",null,null,"主食",null,"（　常食　・　軟飯　・　粥　・　ミキサー　）",null,null,null,null,null,null,null,null,"パン　（ 可 ・不可 ）　　麺　（ 可・不可 ）"]
[null,null,null,null,null,"副食",null,"（　常食　・　一口大　・　刻み　・　極刻み　・　ミキサー　）"]
[null,null,"　義歯",null,null,"（　上 ・ 下 ・ 一部 ・ 無　）",null,null,null,null,null,null,null,"　好きなもの",null,null,null,null,null,"　嫌いなもの"]
[null,null,"　禁食",null,null,"無　・　嗜好　・　服薬　・　その他　　　品目（　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,"　療養食",null,null,"無　・　塩分　・　カロリー　・　その他（　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,"対応内容　（　　　　　　　　　　　　　　　）"]
[null,null,"　その他",null,null,"経管栄養(胃ろう）等についてはこちらに詳細をご記入ください。"]
["清　 潔",null,"　排泄",null,null,null,"　自立　･　見守り　･　一部介助　・　全介助　"]
[null,null,"　日中",null,null,"　トイレ ・ Ｐトイレ ・ 尿器　・ その他　　（　オムツ ・ リハビリパンツ ・ パット ・ 布パンツ　)"]
[null,null,"　夜間",null,null,"　トイレ ・ Ｐトイレ ・ 尿器　・ その他　　（　オムツ ・ リハビリパンツ ・ パット ・ 布パンツ　)"]
[null,null,"　入浴",null,null,null,"　自立　･　見守り　･　一部介助　・　全介助　"]
[null,null,"　入浴の種類",null,null,null,"（　特殊浴　・　中間浴　・　一般浴　・　シャワー浴）"]
[null,null,"　その他"]
["睡 眠",null,"　ベッド　・　床",null,null,null,null,null,null,"センサー使用",null,null,null,"（　有 ・ 無　）",null,null,null,null,"夜間帯の様子"]
[null,null,"　睡眠",null,null,null,"（　良眠　・　浅眠　・　時折不眠　・　不眠　）"]
[null,null,"　眠剤使用",null,null,null,"（　有　・　無　）",null,null,null,"薬名",null,"(　",null,null,null,null,"）"]
["性格等",null,"　性格",null,null,null,null,null,null,null,null,"　趣味",null,null,null,null,null,null,null,"　嗜好（酒・タバコ）"]
[null,null,"　本人の希望　※必須※",null,null,null,null,null,null,null,null,null,null,null,"　家族の希望　※必須※"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"特別養護老人ホームアイリス・アイリス弐番館"]